Mentalizing the Interpersonal Prof Anthony W Bateman Consultant Anna Freud Centre Visiting Professor University College London and Copenhagen University

Mentalizing: What is it?

Summary n  n  n  n  n  n  n  n 

Depression disrupts mentalizing Mentalizing is necessary to change mood Mentalizing is vulnerable to collapse in people with personality disorder People with PD and Depression, a common comorbidity, have a double whammy on mentalizing process Mentalizing develops in attachment process Attachment process underpins interpersonal interaction IPT primary focus is on interpersonal work but interpersonal work can undermine mentalizing IPT clinicians use mentalizing techniques Ø  Could IPT benefit from awareness of mentalizing?

A working definition of mentalization Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).

What is mentalizing?

Mentalizing: further definitions and scope for thinking about it n  n  n  n  n  n  n  n 

To see ourselves from the outside and others from the inside Understanding misunderstanding Having mind in mind Being mind minded Being mindful (of minds) Past, present, and future Seeing oneself as agentive an intentional being Creating phenomenological coherence about self and others

Prementalizing Modes of Subjectivity n 

Psychic equivalence:

Ø  Mind-world isomorphism; mental reality = outer reality; internal has power of external Ø  Intolerance of alternative perspectives èconcrete understanding Ø  Reflects domination of self:affect state thinking with limited internal focus Ø  Managed by avoiding being drawn into non-mentalizing discourse

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Pretend mode: Ø  Ideas form no bridge between inner and outer reality; mental world decoupled from external reality Ø  “dissociation” of thought, hyper-mentalizing or pseudo-mentalizing Ø  Reflects explicit mentalizing being dominated by implicit, inadequate internal focus, poor belief-desire reasoning and vulnerability to fusion with others Ø  Managed in therapy by interrupting a non-mentalizing process

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Teleological stance: Ø  A focus on understanding actions in terms of their physical as opposed to mental constraints Ø  Cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Ø  Extreme exterior focus, momentary loss of controlled mentalizing Ø  Misuse of mentalization for teleological ends (harming others) becomes possible because of lack of implicit as well as explicit mentalizing

Mentalizing, attachment and psychopathology

The two-dimensional space defined by attachment anxiety and avoidance, showing Bartholomew’s 4 categories High avoidance Dismissing avoidant

-ve view of other Fearful avoidant

Low anxiety

High anxiety

+ve view of self

-ve view of self

Secure

Preoccupied Low avoidance +ve view of other

Attachment as Moderator of Treatment Outcome in Major Depression: Interpersonal Psychotherapy Versus Cognitive Behavior Therapy.   McBride,  Carolina;  Atkinson,  Leslie;  Quilty,  Lena;  Bagby,  R  Journal  of  Consul>ng  &  Clinical  Psychology.  74(6):1041-­‐1054,  December  2006.    

Regression lines for posttreatment (A) Ham-D6 and (B) Beck Depression Inventory-II scores as a function of Treatment Condition x Avoidant Attachment

2  

Imbalance of mentalization generates problems Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. BPD ImplicitExplicitImpulsive, quick assumptions Does not genuinely appreciate others’ AutomaticControlled about others thoughts and feelings perspective. Pseudo-mentalizing, Non -conscious- not reflected on or tested, cruelty Interpersonal conflict ‘cos hard to Conscious consider/reflect on impact of self Immediate. Reflective on others BPD Mental Mental Hyper-vigilant, judging exterior interior Lack of conviction about own ideas by appearance. Seeking external reassurance cue cue Evidence for attitudes and other Overwhelming emptiness, internal states hasto come from focused focused Seeking intense experiences outside

Cognitive agent:attitude propositions Imitative frontoparietal mirror neurone System -Other

BPD Unnatural certainty about ideas Anything that is thought is REAL Intolerance of alternative ways of seeing things.

Affective Overwhelming dysregulated emotions, self:affect state Not balanced by cognition come propositions To dominate behavior. Lack of contextualizing of feelings leads to catastrophyzing

BPD Hypersensitive to others’ Moods, what others say. Fears ‘disappearing’

Rigid assertion of self, controlling others’ thoughts and feelings.

Belief-desire MPFC/ACC inhibitory System - Self

Inhibition of social and self/other understanding associated with depression Mood Change

Interpersonal stressors

Inhibition of mentalizing

Loss of affect/low Mood Inaccurate judgements of own affects, hypermentalizing/hypomentalizing cycles Delayed cognitive understanding Failure to understand the situational determinants of emotions

BPD, Depression and Non-mentalizing modes n 

Psychic equivalence Ø Self harm arises in context of disorganised self-structure of BPD Ø Self critical thoughts real Ø Fear of abandonment and loss a fact

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Pretend Mode Ø Hypomentalizing followed by rebound hypermentalizing Ø Self-fulfilling logic of failure and futility Ø Suicide as part of hypermentalizing process

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Teleological Ø Insistent demand for attachment figures Ø Requirement for extra sessions Ø Potential boundary violations

Clinical Characteristics MBT-OPD Number

Exptl N=71

Control n=63

Suicide past 6 months Number of serious self-harm episodes past 6 months Days of hospitalization past 6 months

53

75.0%

42

67.0%

4.1

SD 4.9

3.8

SD 3.7

5.5

SD 11.6

6

SD 12.4

Hospitalized past 6 months

23

32.0%

19

30.0%

Major depressive disorder

41

57.7%

34

54.0%

Depressive disorders -inc dysthymia

56

78.9%

47

74.6%

Posttraumatic stress disorder

9

12.7%

10

15.9%

Number of Axis 1 diagnoses

2.8

SD 1.3

2.8

SD 1.3

Drug misuse (>4x per week)

29

40.8%

26

41.3%

Random-effects meta-analysis: Overall Outcome

Newton-Howes, Tyrer & Johnson (2006), B J Psychiat 188, 13-20

Random-effects meta-analysis stratified by treatment modality: Psychotherapy

Newton-Howes, Tyrer & Johnson (2006), B J Psychiat 188, 13-20

Ten-Year Course of Borderline Personality Disorder:   Psychopathology and Function From the Collaborative Longitudinal Personality Disorders Study
 Arch Gen Psychiatry. 2011;68(8):827-837. doi:10.1001/archgenpsychiatry.2011.37


IPT and mentalizing the interpersonal – a core strategy for comorbidity

Review of the 6th edition of the APA’s Textbook of Psychiatry

IPT Core Strategies n Focal areas: Grief and loss, Role transitions, Interpersonal disputes, Interpersonal sensitivity n Emphasise the current interpersonal relations n De-emphasise current predicament as manifestation of an internal conflict n Explore symptoms in terms of interpersonal relations n Use transference only when obvious or in deficit states n Link symptom change to the way the patient thinks, feels and acts in problematic interpersonal relationships n Don’t uncover distorted thoughts systematically by giving homework n Draw attention to distorted thinking in relation to significant others

Selection, training and supervision in the NIMH trial n 

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Selection of therapists Ø 2-27 years experience, average 11.4 years, prior experience of treating at least 10 depressed clients Ø all candidates screened for competence using CV, interview and video of treatment sessions Training Ø IPT training (from Weissman) - 5 days Ø CBT training (from Beck) - 1-2 weeks Ø monthly, plus call-back if red-line

Ratings of competence n  Therapist

Strategy Rating Form & Process Rating Form – evaluates:

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Ø therapist accuracy in identifying problem areas Ø strategies for bringing about change Ø quality of application of IPT techniques Includes ratings of generic therapeutic skills e.g. Ø Alliance Ø Maintaining session focus

Competence and Outcome – IPT with 3 year maintenance n  Therapists

stratified into high and low competence (median split) n  Median survival time to relapse Ø ‘high’ competence therapists - 2 years Ø ‘low’ competence therapists - 5 months

Assessment of interpersonal/ representational world: Taking the inventory

Interpersonal Inventory n  n  n  n  n  n  n 

Significant contemporary relationships – recent changes, losses, and gains History of current problems and effect on relationships and vice versa Communication styles & patterns of interaction Level of social support Relationship expectations Facilitates planning of treatment interventions Evolves and changes during treatment and may re-orientate therapy

Interpersonal/Relational Processes: Normal

Ø Balanced – selective Ø Flexible – reversible Ø Stable – consistent over time Ø Developmental – change over time and context dependent

Interpersonal/Relational Processes: Attachment patterns n  Centralised

Ø Unstable Ø Self focused Ø Inflexible n  Distributed

Ø Stable Ø Distancing Ø Inflexible

The hierarchy of relationship involvement - Normal Best friend Partner

Most involved

Colleague

Least involved

self self

Intensity of emotional investment Daughter

Mother Teacher

The hierarchy of relationship Best friend involvement Partner

Most involved

Colleague

self self

Least involved Intensity of emotional investment Mother

Daughter

Teacher

Centralised - Unstable

The hierarchy of relationship Best friend involvement Partner

Most involved

Colleague

Least involved

self self

Intensity of emotional investment Daughter

Mother Teacher

Distributed – Relatively stable

The two-dimensional space defined by attachment anxiety and avoidance, showing Bartholomew’s 4 categories High avoidance Dismissing avoidant

-ve view of other Fearful avoidant

Low anxiety

High anxiety

+ve view of self

-ve view of self

Secure

Preoccupied Low avoidance +ve view of other

Assessment: specific aspects Interpersonal World n 

Identify all important current and past relationships but with emphasis on present Ø  Characterise each relationship according to o  o  o  o 

n  n 

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form, process change behaviour

Explore how relationships relate to problems e.g. suicide attempts, self-harm, drug misuse, mood Link patterns in current relationships where similarities exist – ‘that sounds just like you felt with your present partner’ Identify priorities/hierarchy for intervention

Assessment: Interpersonal World n 

Elicit a detailed account of some important current interpersonal interactions in which attachment relationship has been ACTIVATED OR DEACTIVATED e.g. argument with partner Identify common communication difficulties Explore any open conflict with affect storm - outcome Characterize ambiguous, indirect non-verbal communication Delineate incorrect assumptions i.e. that one has communicated or that one has understood Ø  unnecessary, indirect verbal communication Ø  Ø  Ø  Ø 

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Identify silent closing off communication and repetitive statements – ‘I know that I am no good’

n 

Identify faulty communication by listening for the assumptions that the patient makes about other's thoughts or feelings including in therapy dialogue

Assessment: Interpersonal World n 

Common questions Ø  Looking back, can you think a bit about what made her behave like that? Ø  How do you explain his action? Ø  Is that something that has happened before? Ø  Is there any other explanation? Ø  What do other people think about it?

n 

Probes Ø  I can see that you must have wanted to end the relationship but somehow you stuck it out. Tell me what made you carry on. Ø  You must have been so excited when the relationship started and felt so let down when he was unreliable. How did you manage those feelings?

Interpersonal Formulation Biological Factors

Social Factors

Psychological Factors

Recurrent depression in family Hormonal change

Distant relationship with family Separated from husband Good social support at work

Insecure attachment styles Paranoid defences Irritable temperament

Interpersonal Crises: Separation Interpersonal Disputes: family and friends Role transitions: Married to separated Interpersonal Distress Poor work performance

Depression

IPT: Mentalizing the affect

Use of Affect in IPT Present

As I talk about my former partner it makes Content me think of all the things we wanted to do together until he became selfish Affect

Sadness Anger

Past

I mostly remember feeling disbelief that he hadn’t involved me in his arrangements

Numbness

Intervention: Clarification & Affect elaboration n 

Labelling feelings Ø During non-mentalizing interaction therapist firmly tries to elicit feelings states Ø Therapist recognises mixed emotions– probe for other feelings than first, particularly if first emotion is unlikely to provoke sympathy in others or lead to rejection (e.g. frustration, or anger) c.f. basic and social emotions Ø Reflect on what it must be like to feel like that in that situation –’ if that was me I would feel X’ Ø Try to learn from individual what would need to happen to allow them to feel differently Ø How would you need others to think about you, to feel differently?

Affect Focus: Making implicit mentalizing explicit Not the affect associated with the story or event n  Patient may have different affect related to story n  Affect focus is current affect as experienced in the telling of the story n  Make explicit if important in interpersonal terms in patient/clinician relationship n  Naturally moves towards mentalizing the relationship n 

Current affective interpersonal experience = affect focus n  Define

the current affective state shared between patient and therapist n  Do this tentatively from your own perspective n  Do not attribute it to the patient’s experience n  Link the current affective state to therapeutic work within the session itself n  IPAF of Dynamic Interpersonal Therapy

IPT: Mentalizing interpersonal role disputes

INTERPERSONAL ROLE DISPUTES Overall Goals n Help the patient identify the dispute n Determine the form of the dispute n Make choices about a plan of action n Modify maladaptive communication patterns or reassess expectations n Identify pathway of rapidly escalating disputes and emotional arousal

Interpersonal Role Disputes n  Evidence

of current overt and covert conflicts with a significant other Ø Dismissive or over-idealised descriptions of current or recent relationships ‘He betrayed me and so I refuse to talk to him’. ‘Don’t mention him again’

n  Inconsistent

description of relationship within the same narrative Ø ‘I am frightened of him but I love him because he really looks after me’

Common Interpersonal Disputes n  Overt

hostility – domestic violence, abuse n  Betrayals – infidelity n  Psychological dominance – control, sadistic n  Covert hostility – withdrawal, denial of intimacy n  Integration of self-harm in disputes

Misuse of relationship n  Understanding

of the mental state of the individual is not directly impaired yet the way in which it is used is detrimental Ø May be unconscious but is assumed to be motivated Ø Self-serving distortion of the other’s feelings Ø Self-serving empathic understanding Ø A person’s feelings are exaggerated or distorted in the service of someone else’s agenda

Misuse of relationship n  Coercion

against or induction of the thoughts

of others Ø Deliberate undermining of a person’s capacity to think by humiliation Ø Extreme form is sadistic or psychopathic use of knowledge of other’s feelings or wishes Ø Milder form is manipulation for personal gain o inducing guilt o engendering unwarranted loyalty o power games o Understanding used as ammunition in a battle

Interpersonal Role Disputes Tasks 1 n 

Develop a treatment plan: the therapist first determines the stage of the role dispute Ø  Renegotiating Ø  Impasse Ø  Dissolution

n 

Excitement Hurt and abandonment Anger, bitterness,

Identify how non-reciprocal role expectations relate to the dispute Ø  ‘what would be have to do or be like to make you feel better?’

n 

Explore resolution of disputes and role negotiations Ø  ‘Does it ever get better’ ‘Are there times when you make up (beware use of self-harm)’.

Interpersonal Role Disputes Tasks 2 n 

Investigate parallels in previous relationships Ø ‘Have your relationships been like this before’.

n 

What does the patient gain by the behaviour Ø ‘I suppose that sometimes you find all this quite exciting – there is never a dull moment’.

n 

What are the central unspoken assumptions that lie behind it Ø ‘It seems that you are always trying to find out if he loves you’.

Non-reciprocal Roles n  Clarify

expectations of other n  Identify times when roles are fulfilled and times when unfulfilled n  Explore underlying assumptions of role Ø ‘He should look after me – that is what men are supposed to do’ n  Consider

any compromise on roles

Ø If I am like that then perhaps he will be a bit nicer to me’

Interpersonal Disputes - summary Clarification

Expression of affect

Relationship appraisal

Ending of relationship

Communication analysis

Non-reciprocal role expectations

Role playing

Acceptance of relationship limitations

Resolution

Mentalizing the interpersonal: More about how than what.

Therapist Stance n 

Not-Knowing Ø  Neither therapist nor patient experiences interactions other than impressionistically Ø  Identify difference – ‘I can see how you get to that but when I think about it it occurs to me that he may have been pre-occupied with something rather than ignoring you’. Ø  Acceptance of different perspectives Ø  Active questioning Ø  Eschew your need to understand – do not feel under obligation to understand the non-understandable.

n 

Monitor you own misunderstandings Ø  Model honesty and courage to accept mentalizing errors via acknowledgement of your own misunderstanding o  Current o  Future Ø  Suggest that misunderstandings offer opportunities to re-visit to learn more about contexts, experiences, and feelings

Mentalizing Process - trajectory Narrative of event

Experience at time

Reflection on events

Alternative perspective

Experience talking about it in therapy

Current feeling about events

Mentalizing process n  Not

directly concerned with content/ narrative but with helping the patient è Generate multiple perspectives è to free himself up from being stuck in the “reality” of one view (primary representations and psychic equivalence) è to experience an array of mental states (secondary representations) and è to recognize them as such (meta-representation)

Components of mentalizing the therapeutic relationship n  n  n  n  n  n  n 

Validation of experience Exploration in the current relationship Accepting and exploring enactment (therapist contribution, therapist’s own distortions) Collaboration in arriving at an understanding Present an alternative/additional perspective Monitor the patient’s reaction Explore the patient’s reaction to the new understanding

Therapist Affect (Mentalizing the Relationship) n  Focus

the patient’s attention on therapist experience when it offers an opportunity to clarify misunderstandings and to develop prototypical representations Ø Highlight patient’s experience of therapist Ø Use alternative perspectives to emphasise different experience which needs exploring Ø Negotiate negative reactions and ruptures in therapeutic alliance by identifying patient and therapist roles in the problem – accept your contribution

Components of mentalizing the counter-relationship n  Anticipation

of response/reaction of patient n  Mark your statement n  Do not attribute what you experience to the patient n  Keep in mind your aim Ø Re-instate your own mentalizing Ø Identify important emotional interaction that affects therapy relationship Ø Emphasise that minds influence minds

Therapeutic relationship n 

Patient-therapist relationship is not the primary focus of treatment.

n 

Use Transference interpretations sparingly.

n 

Relate patterns in the patient’s relationships to the immediate interpersonal problem.

n 

Give attention to the here-and-now relationship if patient thinks about or acts towards therapist in a way that interferes with the process of therapy

Negative Therapeutic Relationship n 

Encourage patient at the onset of treatment to express to the therapist complaints, apprehensions and/or other negative feelings that arise.

n 

State that the therapy itself is a relationship and so is likely to have problems because the patient is tackling interpersonal difficulties

n 

Explore alternative ways of handling negative reactions both in and out of therapy when they occur

Negative Therapeutic Relationship n 

Explore disruptive attitudes and behaviours by moving from matter-of-fact mention of the behaviour towards attempting to understand its meaning and interpersonal function.

n 

Disruptive behaviour can be understood as indirect and inefficient communication of negative feelings.

n 

If you are responsible for the rupture of alliance APOLOGISE

Thank you for mentalizing! For further information [email protected] Slides available at: http://www.ucl.ac.uk/psychoanalysis/people/bateman

Ten-Year Course of Borderline Personality Disorder:   Psychopathology and Function From the Collaborative Longitudinal Personality Disorders Study
 


Arch Gen Psychiatry. 2011;68(8):827-837. doi:10.1001/archgenpsychiatry.2011.37


Intermediate sessions Specific techniques n 

Limit setting for highly impulsive individuals whose behaviour is destructive

n 

Directive techniques (educating, advising, modelling)

n 

Role playing to facilitate behaviour change

n 

Decision analysis whenever the patient has an interpersonal problem to be solved - "What alternatives do you feel you have now?" or "Why don't we try to consider all the choices you have?".

Theory Self Development n 

n 

n 

that the agentive, mentalizing, psychological sense of self is rooted in the attribution of mental states; that this capacity emerges through interaction with the caregiver, in the context of an attachment relationship, via a process of mirroring. that this capacity may be inhibited (decoupled) in response to trauma in vulnerable individuals

Focal Area for BPD – The Self n  Self

(a muddled concept)

Ø Initiator of action Ø Experience of personal agency Ø Psychological structure Ø Superordinate structure (Kohut) Ø Defensive structure (False Self – Winnicott) Ø Autonomous strivings (Masterson)

Focal Area for BPD – The Self n A structure through which an individual acquires continuity, cohesion, and enduring organization Ø Self-representations – how I portray myself to myself Ø Self-identity – broad category Ø Self-concepts – how I describe myself Ø Self-image – how I see myself Ø Self-esteem – affective evaluation of self Ø Self-schema – mental model with prototypical interactions

Focal Area for BPD – The Self n  Explore

view of self in multiple interpersonal contexts – relationships, social occasions, work, family Ø ‘How would you describe yourself when..’ Ø ‘How do you see yourself as a person’ Ø ‘How does she make you feel about yourself’ Ø ‘Who can make you feel good about yourself’ Ø ‘Who do you like to be with. How do you explain that?’

Standard IPT Structure – early sessions n  n  n  n  n  n  n  n  n 

Review of symptoms Give disorder a name Explain the disorder Define and explore Interpersonal Inventory Giving the ‘sick role’ Evaluation of need of medication Define interpersonal context Give the model – emphasise current Agree on treatment contract

Rationale for IPT for BPD n 

n  n  n  n 

BPD a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked instability Symptoms (affects) primarily provoked in interpersonal situations IPT targets affects within interpersonal contexts IPT emphasises therapeutic alliance BPD involved in interpersonal disputes and IPT specifically explores disputes and role expectations

Review of Borderline Symptoms n  n  n  n  n  n  n  n  n 

frantic efforts to avoid real or imagined abandonment a pattern of unstable and intense interpersonal relationships identity disturbance impulsivity in at least two areas that are potentially selfdamaging recurrent suicidal behaviour affective instability due to a marked reactivity of mood chronic feelings or emptiness inappropriate, intense anger or difficulty controlling anger transient, stress-related paranoid ideation

Aims of early sessions – IPT for BPD n  Establish

therapeutic relationship n  Identify affective states n  Define interpersonal inventory n  Link interpersonal context to behaviours and symptoms n  Explicate pathway to improvement

Modifications of IPT structure and content n  Conceptualisation n  Focus

of disorder

of therapy n  Length and frequency of intervention n  Integration of risk and pathway in crisis n  Termination n  Maintenance IPT

Length of Treatment n  No

evidence that very brief treatments effective in BPD so IPT-BPD has two stages Ø IPT 16-24 sessions plus telephone contact and emergency pathway Ø Additional 16 sessions over 16 weeks if initial phase tolerated Ø ?IPT- M

Provision of Information: Expert Role n  Information

– personalised - ?Leaflet

Ø Understanding of BPD o Genetics o Biological processes – arousal, hormonal pathways o Neurobiology – emotional circuitry o Developmental o Interpersonal inventory

Focus on Affect n  Experience

near n  Identify common affects of BPD – anger, anxiety, abandonment, emptiness n  Explore interpersonal context of emotion n  Identify patterns of affect storms n  Chart fluctuations – BPD is a relapsing and remitting disorder

The Patient and Affect n 

The patient must be helped to: Ø  Consider who engendered the feeling and how Ø  Ask ‘what feeling may I have engendered in someone else that may have made him do that to me’? Ø  Explore whether the feelings have occurred or are connected to events either in the immediate or longer term past but IPT works predominantly in the present Ø  Assess the appropriateness of the feeling to any given situation in terms of others’ understanding of them Ø  Establish the appropriate locus of these feelings within current relationships

Use of Affect in IPT n  Distinguish

between process or present affect i.e. expressed in session and content or past affect i.e. as reported n  Explore incongruities between them n  Help patient become aware of underlying affects e.g. depression covers anger, anger covers hurt

Use of Affect in IPT Present

As I talk about my former partner it makes Content me think of all the things we wanted to do together until he became selfish Affect

Sadness Anger

Past

I mostly remember feeling disbelief that he hadn’t involved me in his arrangements

Numbness